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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Stop N Shop I Date of Testing: January 18,2017 <br /> Facility Address: 1856 Country Club Blvd.,Stockton,Ca.95206 <br /> Facility Contact: Harwinder Bhatia(Sonny) Phone: (209)222-2220 <br /> Date Local Agency Was Notified of Testing: 1/3/2017,by Afford-A-Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's Jul 30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ I ❑ <br /> Piping Sump#2 X I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ r ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ k„`�`7 , _� Li <br /> Ll [I El 11 [1 .. ❑ .,_.❑ ❑ <br /> ❑ ❑ ❑ ❑ JUN ZLL2017 ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ DEE-A1]:UJEQ1 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ��atr�. a!/l�s2atil2 Date: January 18,2017 <br />